o In any given year 18% of people will suffer from an anxiety disorder. The four most common anxiety disorders in primary care are: panic, generalized anxiety disorder, social anxiety disorders and PTSD. Of these Generalized Anxiety Disorder (GAD) is the most common.
Epidemiology/risk factors:
o Lifetime prevalence rate is 4.1%. Twice as many women as men have GAD. Accounted for 12.3 million office visits (1997-1998). Majority of patients have comorbid psychiatric disorder including: major depression/panic disorder/social phobia/specific phobia/OCD/PTSD and substance abuse.
o Risk Factors: Family History/ stressful life events/ history of childhood physical or emotional abuse
Symptoms/Diagnosis:
o Symptoms: excessive anxiety and worry about a number of events or activities, occurring more days than not for at least 6 months, that are out of proportion to the likelihood or impact of feared events. Somatic symptoms may include fatigue, muscle tension,memory loss and insomia. (DSM IV: http://gad.about.com/od/symptoms/a/dsmiv.htm)
o Diagnostic Tool: The GAD-7 Anxiety Scal (printable PDF) A score of 10 or more on the GAD-7 represents a reasonable cut point for identifying cases of GAD. The sensitivity at this level was 89%, and the specificity was 82%. Cut points of 5, 10, and 15 may be interpreted as representing mild, moderate, and severe levels of anxiety on the GAD-7.
Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all sure
Several days
Over half the days
Nearly every day
Feeling nervous, anxious, or on edge
0
1
2
3
Not being able to stop or control worrying
0
1
2
3
Worrying too much about different things
0
1
2
3
Trouble relaxing
0
1
2
3
Being so restless that it's hard to sit still
0
1
2
3
Becoming easily annoyed or irritable
0
1
2
3
Feeling afraid as if something awful might happen
0
1
2
3
Add the score for each column
Total Score (add your column scores)
Treatment and follow-up:
Step 1: SSRI Step 2: Non-response after adequate SSRI trial can be followed by a different SSRI, SNRI, TCA. Partial response can be followed with buspirone or hydroxyzine. Step 3: Non-response after adequate trials of second-line antidepressants can be followed with trials of other less well studied antidepressants. Partial response can be addressed by augmentation.
MEDICATIONS:
SSRI approved for GAD: Escitalopram(lexapro) no CYP450 interactions (not covered consider Citalopram(Celexa)) Paroxetine(Paxil) shorter half life so higher risk of breakthrough anxiety and CYP450 effects (2D6 inhibitor so interacts with Metoprolol)
SNRI approved for GAD: Venlafaxine (effexor) no CYP450 effects shorter half life
Other SSRI commonly used for GAD: Fluoxetine(Prozac) most stimulating but longer half life so less breakthrough Sertraline (Zoloft) intermediate half life minimal CYP450 effects but has diarrhea
General:
o In any given year 18% of people will suffer from an anxiety disorder. The four most common anxiety disorders in primary care are: panic, generalized anxiety disorder, social anxiety disorders and PTSD. Of these Generalized Anxiety Disorder (GAD) is the most common.
Epidemiology/risk factors:
o Lifetime prevalence rate is 4.1%. Twice as many women as men have GAD. Accounted for 12.3 million office visits (1997-1998). Majority of patients have comorbid psychiatric disorder including: major depression/panic disorder/social phobia/specific phobia/OCD/PTSD and substance abuse.o Risk Factors: Family History/ stressful life events/ history of childhood physical or emotional abuse
Symptoms/Diagnosis:
o Symptoms: excessive anxiety and worry about a number of events or activities, occurring more days than not for at least 6 months, that are out of proportion to the likelihood or impact of feared events. Somatic symptoms may include fatigue, muscle tension,memory loss and insomia. (DSM IV: http://gad.about.com/od/symptoms/a/dsmiv.htm)o Diagnostic Tool: The GAD-7 Anxiety Scal (printable PDF)
A score of 10 or more on the GAD-7 represents a reasonable cut point for identifying cases of GAD. The sensitivity at this level was 89%, and the specificity was 82%. Cut points of 5, 10, and 15 may be interpreted as representing mild, moderate, and severe levels of anxiety on the GAD-7.
Treatment and follow-up:
Step 1: SSRI
Step 2: Non-response after adequate SSRI trial can be followed by a different SSRI, SNRI, TCA. Partial response can be followed with buspirone or hydroxyzine.
Step 3: Non-response after adequate trials of second-line antidepressants can be followed with trials of other less well studied antidepressants. Partial response can be addressed by augmentation.
MEDICATIONS:
SSRI approved for GAD:
Escitalopram(lexapro) no CYP450 interactions (not covered consider Citalopram(Celexa))
Paroxetine(Paxil) shorter half life so higher risk of breakthrough anxiety and CYP450 effects (2D6 inhibitor so interacts with Metoprolol)
SNRI approved for GAD:
Venlafaxine (effexor) no CYP450 effects shorter half life
Other SSRI commonly used for GAD:
Fluoxetine(Prozac) most stimulating but longer half life so less breakthrough
Sertraline (Zoloft) intermediate half life minimal CYP450 effects but has diarrhea
CCHP Covers:
Buspar(buspirone)
Bupropion (Wellbutrin)
Citalopram (Celexa)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Venlafaxine (Effexor)
Monitor improvement with OASIS tool (appendix 2 of reference 2)
http://www.chammp.org/Training/Resources/Assessment-Tools/Anxiety.aspx
Articles/References:
1. Roy-Byrne P et al. Brief intervention for anxiety in primary care patients. J AM Board Fam Med 2009; 22:175-86 (http://www.jabfm.org/content/22/2/1.full)
2. Fricchione G. Generalized anxiety disorder. NEJM 2004; 351(7):675-82
3. UpToDate